Triangulating Healthcare Lessons

It’s often hard to see the Big Picture in healthcare unless you read enough sources and know enough about the topic to be able to triangulate stories. A marvelous example of multiple stories describing different parts of the same big picture became apparent over the past few days in the form of two posts from Dr. Scot Silverstein on the Health Care Renewal blog, a post by Dr. Richard Fogoros (aka, “Dr. Rich”) on The Covert Rationing Blog and an article by an insurance executive on Bloomberg. Individually they are interesting, but together they tell a marvelous tale that really gets at the truth about the American experience of Hellth. Let’s begin with Dr. Silverstein. As many of our regular readers may know, Dr. Silverstein is an expert on medical information systems and frequently writes about electronic health records (EHRs, aka EMRs), both on the HCR blog and on this excellent website that he maintains specifically for the purpose of bringing problems with these technologies to light. In his first post, Dr. Silverstein comments on news of a recent large RAND Corporation study that was supposed to demonstrate the extent to which EHRs improved the quality of care provided by hospitals. He quotes the news article in his blog post, with annotations:

“The RAND study is one of the first to look at a broad set of hospitals to examine the impact that adopting electronic health records has had on the quality of care.

The research included 2,021 hospitals – about half the non-federal acute care hospitals nationally. Researchers determined whether each hospital had EHRs and then examined performance across 17 measures of quality for three common illnesses – heart failure, heart attack and pneumonia. The period studied spanned from 2003 to 2007.

:

The number of hospitals using either a basic or advanced electronic health records rose sharply during the period, from 24 percent in 2003 to nearly 38 percent in 2006. [How many billions of dollars diverted from patient care needs does that represent? – ed.]

Researchers found that the quality of care provided for the three illnesses generally improved among all types of hospitals studied from 2004 to 2007. The largest increase in quality was seen among patients treated for heart failure at hospitals that maintained basic electronic health records throughout the study period.

However, quality scores improved no faster at hospitals that had newly adopted a basic electronic health record than in hospitals that did not adopt the technology.

[In other words, the improvements or lack thereof had little to do with electronic vs. paper record keeping – ed.]

In addition, at hospitals with newly adopted advanced electronic health records, quality scores for heart attack and heart failure improved significantly less than at hospitals that did not have electronic health records.

[In other words, the clinical IT was probably impairing doctors compared to simpler paper methods and good HIM personnel – ed.]

EHRs had no impact on the quality of care for patients treated for pneumonia.”

Now ordinarily you might expect that the conclusion of a study like this would be that we should be re-thinking our nation’s approach to EMRs. After all, American hospitals and physicians are being forced by the federal government to spend billions upon billions of dollars and uncounted hours deploying these things, or else face severe financial penalties. But that’s not the conclusion that the investigators at RAND would like us to reach. Instead, we are presented with this rather dubious conclusion, which Dr. Silverstein rightly questions:

‘”The lurking question has been whether we are examining the right measures to truly test the effectiveness of health information technology,” said Spencer S. Jones, the study’s lead author and an information scientist at RAND. “Our existing tools are probably not the ones we need going forward to adequately track the nation’s investment in health information technology.”[“Probably” not the ones we need? How can Jones know this? This is not science, it is speculation. Further, I’d say the scientific imperative before we design “the right measures” to “truly” test the effectiveness of HIT is to understand why the measures we’re using now are not showing the desired results, because perhaps they are perfectly adequate and are revealing crucial flaws, overestimations and false assumptions that need to be dealt with, now, not after another round of billions is spent – ed.]New performance measures that focus on areas where EHRs are expected to improve care should be developed and tested, according to researchers.[In pharma clinical trials, this is akin to what is known as “changing the study methodologies and endpoints” – a form of manipulating clinical research, usually with the true ultimate endpoint of money – ed.]”

The real point here is that it seems that even the most “scientific” EHR proponents (let alone the political or corporate ones) would never accept that the current complex, expensive and unwieldy EHRs are of little or no net clinical value, no matter what any study shows. (It’s a little like that old aphorism, “My mind is made up, don’t confuse me with the facts.”)
So if these things are so expensive and disruptive to providers, and yet they are being deployed anyway, what’s behind the trend? Well one obvious answer is that the corporations who manufacture EHRs have done an excellent job lobbying Congress and the Obama administration. Heck, given the roughly $20 billion devoted to “encouraging” the purchase of EHRs in the 2009 stimulus bill, there can be little doubt about that. But Dr. Silverstein’s second post hits upon another reason – the battle to secure payment on the part of hospitals, and deny payment on the part of insurers. A financial cyber war if you will. This post is entitled: “Inpatient or outpatient and the battle to control costs: The truth about the push for electronic medical records?”, and it explores the conflict between hospitals and insurers about what constitutes “in-patient” versus “out-patient” care. Since the former pays more than the latter, considerable amounts of money are at stake. From the blog:

“’… Joanne Mainart and Donna Tobin are nurses and case managers at Abington who review admissions. Mainart was hired for this job a year ago; Tobin joined her in March.

They sit at their own computer in the ER [i.e., with their own access to the EHR – ed.], away from patients, and when they see a black ball beside a patient’s name [signifying the insurer may deny an inpatient claim and pay at aforementioned “outpatient inpatient” rates – ed.], their job is to examine medical records and treatments and determine if the patient meets criteria for inpatient admission.

Doctors still make the decision. These nurses only advise. But their mission is to make sure patients get put in the right category – inpatient admission or observation [so the hospital can be paid appropriately – ed.]

Assigning Mainart and Tobin to the ER was Abington’s response to the push toward observation.

And this:

… Blue Cross has its own team of utilization review nurses, all of whom, it says, have at least five years experience and have received special training in utilization review.

One of the nurses, working at the Blue Cross offices in Plymouth Meeting, got access to Abington’s computers through a secure logon [they can see the EHR too! – ed.] and reviewed the same records Tobin had the previous evening.

[Note the centrality of the computers in this payment “poker game” process – ed.]

The Blue Cross nurse did not feel Klein [the patient whose case is discussed in this article] met InterQual.

[Since nurses cannot unilaterally make these decisions, a physician later reviewed the case and concurred – ed.]

So, there we have it.

Physicians’ work is interfered with by EHR’s ostensibly put in place to “help them”, but in reality a behind-the-scenes cybernetic game of financial chess is going on, worth billions to hospitals and the insurers.

If that is not a compelling driver for EHR technology, I don’t know what is.”

All righty then. It’s not really about quality at all, it’s really about money. After all, if EHRs were a drug or a medical device, Medicare and all of the other insurance companies would have required the manufacturers to demonstrate that they were safe, effective and improved the quality of care before ever allowing them to be sold and used by patients and providers in the healthcare marketplace. But if you listen to the high-minded pronouncements of folks like Medicare chief Dr. Don Berwick, there is still another function that is commonly used to justify the huge amounts of time and money spent on EMRs. It’s that all of the vast amounts of electronic data that they’ll create will somehow be useful for creating new, improved and evermore effective centralized rules for doctors to follow when providing healthcare services. All of these “optimized” and sophisticated guidelines will reduce the errors that physicians are guilty of making. Care will be improved, costs will go down and lives will be saved. This argument for the power and might of EHRs, and the centralized decision making they make possible, leads us to this post by Dr. Rich. In it, he discusses this idea advanced from the left by people like HHS Secretary Kathleen Sebelius, and Medicare chief Don Berwick, and from the right, by The Cato Institute’s economist Arnold Kling:

“For example, a few years ago the noted economist Arnold Kling strongly defended the idea. ‘My own view is that a remote third party probably can use statistical evidence to make good recommendations for a course of treatment.’

Now, Kling is no far-left radical, pushing for centralized control of healthcare (and everything else). Indeed, he is now with the Cato Institute, and before that he taught economics at George Mason University. So he has earned his conservative and/or libertarian chops.

And to be fair, he is not really calling here for “remote third parties” to have final authority on what’s best for individual patients. Rather, he thinks patients should make that decision for themselves, weighing the recommendations of data-driven guidelines promulgated by remote experts, against the ego-toss’d recommendations from their all-too-fallible doctors, or, as Kling sarcastically refers to them, their “heroic personal saviors.” (Such sarcasm, regular readers will know, is as abhorrent to DrRich as it probably is to you.) Kling is saying: trust patients, armed with good evidence-based recommendations handed down from experts, to make the right decisions for themselves.”

Dr. Rich finds several faults with this approach, but here we’re mostly interested in the first one:

“The first flaw, of course, is the idea that remote third parties, wielding evidence-based data, can make good treatment recommendations for individual patients. Evidence-based guidelines, almost by definition, are designed to improve the average outcome across a population of individuals, and are specifically designed not to optimize outcomes for each individual within that population.”

Which leads to our final point of triangulation – a poignant article by health insurance executive David Klein. In his article, Mr. Klein tells us of the frustration he felt when seeking answers for the treatment of his wife Linde’s oral squamous cell carcinoma, and how it led him to understand that good medical care simply cannot be approached as an all-knowing, centralized process:

“What Linde and I have learned over the past two years has broadened my fundamental beliefs about medicine. In sum, while amazing advances have been made and miracles are occurring, medicine remains very much an art.

I’ve spent almost 40 years on the business side of the health-care industry, including the last seven as chief executive officer of a health plan. I believed my network of contacts would serve us well. I presumed there were unambiguous answers to questions about the best treatment plan and the best providers.

What I learned was that for uncommon diseases like Linde’s, if not all diseases generally, clear answers often don’t exist. I will never forget one doctor telling me that the information I sought wasn’t available and that I would have to trust my gut. This is pretty incredible when you think about how much as a society we spend on health care.

The new federal health-care reform law promotes the adoption of health-information technology and supports comparative effectiveness research to understand the marginal contributions of new drugs, devices and procedures. But what we learned with Linde’s treatment is that data on innovations, especially for less common diseases, isn’t sufficient to broadly create evidence-based medicine.”

Together these articles cover an enormous amount of ground, but the central message is that we’re making a big mistake if we think that coercing our doctors into using expensive and complex information technology and following the edicts of centralized “panels of experts” is going to get us where we want to go as patients. These are the obsessions and grand managerial plans of people who really don’t know much about doctors, patients and the real-world of delivering and receiving healthcare services. People in government bureaucracies, insurance companies, think tanks and academic medical centers, whose livelihoods depend upon claiming to be smarter, better informed and more creative than clinicians who actually deliver the care. These regulators and technocrats have now been in charge and working their will on healthcare for over 20 years. How’s that been working out? Not so well. That should be apparent to anyone who will just look around and connect the dots.